Medication Appropriateness Index Research Articles

Effects of medication management in geriatric patients who have fallen: results of the EMMA mixed-methods study.

comprehensive medication management (CMM) can reduce medication-related risks of falling. However, knowledge about inter-individual treatment effects and patient-related barriers remains scarce. to gain in-depth insights into how geriatric patients who have fallen view their medication-related risks of falling and to identify effects and barriers of a CMM in preventing falls. complementary mixed-methods pre-post study, based on an embedded quasi-experimental model. geriatric fracture centre. qualitative, semi-structured interviews framed the CMM intervention, including a follow-up period of 12weeks. Interviews explored themes of falling, medication-related risks, post-discharge acceptability and sustainability of interventions using qualitative content analysis. Optimisation of pharmacotherapy was assessed via changes in the weighted and summated Medication Appropriateness Index (MAI) score, number of fall-risk-increasing drugs (FRID) and potentially inappropriate medications (PIM) according to the Fit fOR The Aged and PRISCUS lists using parametric testing. thirty community-dwelling patients aged ≥65years, taking ≥5 drugs and admitted after an injurious fall were recruited. The MAI was significantly reduced, but number of FRID and PIM remained largely unchanged. Many patients were open to medication reduction/discontinuation, but expressed fear when it came to their personal medication. Psychosocial issues and pain increased the number of indications. Safe alternatives for FRID were frequently not available. Psychosocial burden of living alone, fear, lack of supportive care and insomnia increased after discharge. as patients' individual attitudes towards trauma and medication were not predictable, an individual and longitudinal CMM is required. A standardised approach is not helpful in this population.

Assessment of medication discrepancy, medication appropriateness, and cost analysis among patients with pediatric nephrotic syndrome: An ambispective cohort observational study

BackgroundNephrotic syndrome (NS) is a commonly encountered chronic kidney disease in pediatric populations, with South Asian children being at high risk and requiring long-term pharmacological management. Thus, identifying medication discrepancies and evaluating the appropriateness of therapy and its economic burden are vital for inpatient management. The aim of the study was to assess medication reconciliation, medication appropriateness, and cost analysis in NS cases. MethodsAn ambispective cohort observational study was carried out with 150 NS patients where medication discrepancies were identified retrospectively and prospectively using the best possible medication history and following up patients correspondingly. Further, the Medication Appropriateness Index and cost variation analysis were used to assess the prescribed therapy and cost analysis, respectively. ResultsOut of 150 patients with NS included, 67.3% were male and the mean age was 7.2 years. In total, 36.7% medication discrepancies were found at baseline and 6% discrepancies at follow-up. The majority of discrepancies were unintentional and due to dosing error both at baseline and follow-up. Further, in only 2% of the patients was there inappropriately prescribed medication, and the majority of patients spent between INR (Indian Rupees) 500 and 1000. ConclusionChronic conditions like NS require continuous monitoring by the specialist pediatric clinical pharmacist, who can contribute significantly by minimizing the medication discrepancies, by assessing the appropriateness of therapy, and lessening the economic burden.

Older adults’ attitudes towards deprescribing and medication changes: a longitudinal sub-study of a cluster randomised controlled trial

ObjectiveTo investigate the association between older patients’ willingness to have one or more medications deprescribed and: (1) change in medications, (2) change in the appropriateness of medications and (3) implementation...

Rationalizing prescription via deprescribing in oncology practice.

To provide an integrated approach for deprescribing practice in oncology setting. The data on deprescribing in oncology settings has been retrieved from the PubMed, Scopus and Google Scholar. We used "deprescribing," "potentially inappropriate medication" and "cancer" as a keyword for the conducting general search. The articles relevant to guidelines or tools used to deprescribe in cancer care were included. The nature of cancer, its treatment strategies, adverse effects of therapy and multimorbidity impact negatively on quality of life (QoL). Further, they invite polypharmacy which puts the patient at higher risk of drug-related problems like drug interactions, adverse drug reactions and addition of potentially improper medications, etc. In older adults with cancer, the incidence of potentially inappropriate medications (PIMs) was between 41% and 52%. Over the decades, multiple strategies have been developed to assess the appropriateness of therapy. One such approach is deprescribing. OncPal and oncoSTRIP (Systematic Tool to Reduce Inappropriate Prescribing) are the cancer specific guidelines whereas BEERs criteria, Screening Tool to Alert to Right Treatment/Screening Tool of Older Person's Prescriptions criteria (START/STOPP criteria), medication appropriateness index (MAI) are the cancer nonspecific tools to identify PIM among cancer patients. Here, we provided an integrative approach and algorithm for deprescribing in oncology setting which includes patient and caregiver goals, life expectancy (LE), review of medications, determining medication appropriateness, assessment of time to benefit (TTB), symptomatic and asymptomatic care, identifying medications to cease, implementation of the plan, monitoring and reviewing. Deprescribing in oncology setting is a novel and effective patient-centric approach to counteract the use of PIM, which helps to mitigate polypharmacy, drug-drug interactions, and adverse effects.

Polypharmacy and Deprescribing for Older Adults

Polypharmacy, which refers to using multiple medications by an individual, is becoming increasingly common in the aging population. Although it can be beneficial in treating complex medical conditions, it also carries inherent risks, such as adverse drug reactions, drug interactions, cognitive impairment, and increased healthcare costs. With increased medication use, it is essential to consider the risks and benefits of each prescribed medication. Evidence-based guidelines, such as the Beers Criteria and the Screening Tool of Older Persons’ Prescriptions criteria, can help healthcare providers reduce the risks of polypharmacy. Deprescribing, the process of reducing or stopping medication use that is no longer necessary or potentially harmful, is becoming increasingly important in managing polypharmacy. The 5Rs Framework and the Medication Appropriateness Index are two examples of clinical practice guidelines for deprescribing. Communication and collaboration between healthcare providers and patients, gradual tapering of medication, and involvement of patients and caregivers in decision-making are important considerations for deprescribing in primary care. This article provides an overview of the prevalence and negative consequences of polypharmacy, evidence-based guidelines for reducing polypharmacy, clinical practice guidelines for deprescribing, and considerations for deprescribing in primary care.

Study Protocol for the Evaluation of Multidisciplinary Medication Reconciliation Service in Adult Patients Undergoing Thoracic and Cardiovascular Surgery (The MERITS Study): A Single-Center Controlled before-and-after Study.

Medication reconciliation (MR), which is widely implemented worldwide, aims to improve patient safety to reduce the medication errors during care transition. Despite its widespread use, MR has not yet been implemented in the Republic of Korea, and its effectiveness has not been studied. We aimed to evaluate the impact of a multidisciplinary MR service in older patients undergoing thoracic and cardiovascular surgery. This is a single-center, prospective, controlled, before-and-after study of adult patients taking at least one chronic oral medication. Depending on the period of each patient's participation, they will be allocated to an intervention group or control group. Patients in the intervention group will receive multidisciplinary MR, and those in the control group will receive usual care. The primary outcome is to assess the impact of the MR service on medication discrepancies between the best possible medication history and medication orders at care transition. Secondary outcomes include the incidence rate of medication discrepancies at each transition, the discrepancy rate between the sources of information, the impact of MR on medication appropriateness index score, drug-related problems, 30-day mortality, the emergency department visit rate, readmission rate after discharge, the rate and acceptability of pharmacists' intervention during hospitalization, and patients' satisfaction.

Optimising prescribing in older adults with multimorbidity and polypharmacy in primary care (OPTICA): cluster randomised clinical trial

ObjectiveTo study the effects of a primary care medication review intervention centred around an electronic clinical decision support system (eCDSS) on appropriateness of medication and the number of prescribing omissions...

Patient perspectives on, and effects of, medication management in geriatric fallers (the EMMA study): protocol for a mixed-methods pre-post study

IntroductionPharmacotherapy is critical in geriatric fallers owing to the vulnerability of this population. Comprehensive medication management can be an important strategy to reduce the medication-related risk of falling in this...

Assessment of Knowledge, Attitude and Practices of the Hospital and Community Pharmacists in Saudi Arabia (Jeddah) towards Inappropriate Medication Use in Older Adults.

In Saudi Arabia, the older adult population is growing and is projected to increase three-fold by 2030. Potentially inappropriate medications (PIMs) are harmful to older adults' and have a direct impact on clinical, health and economic outcomes. Pharmacists have a vital role in medication tailoring for older adults as multidisciplinary team members. However, there is also a paucity of research regarding pharmacists' participation in detecting and avoiding PIMs use among older adults in Saudi Arabia. A cross-sectional, self-administered survey was conducted to assess the knowledge, practices, and attitude of pharmacists from seven hospitals and ten community pharmacies in Jeddah, Saudi Arabia. The survey comprised three sections; (i) identifying participants' general characteristics, (ii) assessing their knowledge of PIMs use in older adults and (iii) examining the pharmacist's attitude towards the procedures followed in dispensing for older adults. Inferential and descriptive statistics were used to analyse the survey data. A total of 157 community and hospital pharmacists participated in this study. Most of them dispensed medication weekly to older adults (85.4%), and 43.3% had relevant work experience of six to ten years. Though 44.6% of the participants were aware of PIMs that older adults should avoid, only 10.8% claimed adequate knowledge about PIMs. From the given three clinical case scenarios, a minority of pharmacists (21.7%) chose the correct answers, with a mean score of 2.38 ± 2.91 (95% CI 2.35-3.15). Participants who claimed to have knowledge of PIMs had a significantly higher mean score than those who did not, 4.59 ± 2.81 25 (95% CI 2.35-2.61). A minority of the pharmacists (14.7%) used screening tools such as STOPP, Beers criteria, or Medication Appropriateness Index (MAI) to detect PIMs in older adults. No statistically significant differences were detected when comparing the levels of knowledge of pharmacists with 1 to 5 years of practice to pharmacists with 6 to 15 and more years of experience (p = 0.431). Pharmacists' knowledge, attitude and practices toward PIMs use in older adults in Saudi Arabia should be improved. The application of PIMs detection tools such as STOPP/START or Beers criteria currently has no place in day-to-day pharmacists' roles in Saudi Arabia. Therefore, concerned stakeholders should develop educational programs to improve pharmacists' knowledge of PIMs and promote the effective use of PIM screening tools such as Beers and STOPP criteria in their practice.

Understanding Prescribing Cascades: Evaluating Risks and its Management

Prescribing cascade occurs when an adverse drug event is misinterpreted as a new medical condition resulting in a new medication being prescribed to treat the adverse drug event. A simple example is prescription of a proton pump inhibitor(PPIs) to counteract the acid reflux caused by non-steroidal anti-inflammatory drugs(NSAIDs). An interconnection between polypharmacy and prescribing cascade is established where both have a direct influence on each other. Prescribing cascade can affect people of any age but has shown to frequently affect the elderly patients. Assessment tools include both simpler ways like effective communication, clinical process mapping, NO TEARS checklist and complex algorithms like the Screening Tool for Potentially Inappropriate Prescriptions (STOPP), Beers criteria, Medication Appropriateness Index. Identifying and disrupting the prescribing cascade is an important, feasible, and undervalued opportunity to improve patient drug safety.

Polypharmacy in Elderly People: A Simple Review

With increasing age, there is chance of developing different chronic conditions which are often accompanied by use of multiple medicines that can lead to polypharmacy which can be defined as use of five or more medicine which include the one that has been prescribed, over the counter (OTC) as well as complementary medicine. Geriatric people particularly those with multiple co-morbid health conditions, may develop polypharmacy with high risk of Adverse Drug Events (ADE) and Drug Interaction (DI). Presence of multiple co-morbidities makes them the highest consumer of pharmaceutical drugs, so a high degree of caution is required while prescribing drug to the elderly population. Concept of Deprescribing and several tools like Medication Appropriateness Index, ARMOR (Assess, Review, Minimize, Optimize, and Reassess), and START/STOPP (Screening tool for older persons potentially inappropriate prescription/ Screening tool to alert doctors to right treatment) etc have emerged as practical guides to solve problems related to polypharmacy and these tools should be considered by the prescriber while prescribing the drug to the elderly population.

Decision support software-guided medication reviews in elderly patients with polypharmacy: a prospective analysis of routine data from community pharmacies (OPtiMed study protocol).

Pharmacist-led medication reviews are considered a valuable measure to address risks of polypharmacy. The software Medinspector® is used in community pharmacies to assist the performance of this complex service by structuring the medication review process and supporting pharmacists in their decision-making with targeted clinical knowledge. Key feature is a computerized risk assessment of both the initial and adjusted medication regimen of a patient in multiple domains, thus aiming to support the identification and solving of drug-related problems. This study will examine the effects of medication reviews performed with the clinical decision support system in daily routine practice on medication-related and patient-reported outcomes in elderly patients with polypharmacy. A prospective, before-after observational study is conducted in German community pharmacies aiming to include 148 patients aged 65 or older, who chronically use five or more active pharmaceutical substances with systemic effects and utilize the software-supported medication review service. The study is based on routine documentation within the software over the course of the medication review, including a patient's baseline medication, the medication proposed by pharmacists, and the final medication regimen. A software-implemented questionnaire comprising self-developed and literature-derived instruments is used to collect patient-reported outcome data at baseline and follow-up. Primary outcome is the appropriateness of medication measured with an adapted version of the Medication Appropriateness Index (MAI). Secondary medication-related outcomes are medication underuse, exposition towards anticholinergic/sedative drugs, number of drugs in long-term use and the implementation of pharmacist-proposed medication adjustments by the physicians. Secondary patient-reported outcomes are symptom burden, medication-related quality of life, adherence, fulfillment of medication review-related goals, and perception of the service. With the recently introduced remuneration of community pharmacist-led MR in Germany, the demand for digital tools supporting the MR process is assumed to rise. The OPtiMed-study is expected to create evidence on the effects of a novel tool on patient care in a vulnerable patient population. Trial registration German Clinical Trials Register, DRKS00027410. Registered 22 December 2021, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00027410 . Also available on the WHO meta-registry: https://trialsearch.who.int/?TrialID=DRKS00027410.

Clinical Pharmacist Intervention Reduces Potentially Inappropriate Prescriptions in a Geriatric Perioperative Care Unit Dedicated to Hip Fracture

Introduction: Clinical pharmacist (CP) intervention improves drug prescription by identifying potentially inappropriate prescriptions (PIPs). Geriatric perioperative care units (UPOGs) provide enhanced care for patients with hip fracture, including drug prescription. However, it is not known whether adding a CP intervention in a UPOG decreases the number of PIPs. This study aimed to evaluate the effect of a CP intervention, combining an implicit and an explicit method, on the number of PIPs in a UPOG. Methods: This single centre before-after-control-impact study recruited patients aged over 75 years admitted to a UPOG for a hip fracture. The “control group” (“before period”) received usual care including two medication reconciliations, one at admission and one at discharge. The “intervention group” (“after period”) received usual care and a CP intervention including two medication reconciliations, a medication review with two tools, STOPP/START and Medication Appropriateness Index, and a meeting between a CP and geriatricians. PIPs were assessed in both groups by STOPP/START and Medication Appropriateness Index and compared from hospital admission to discharge. Results: A total of 209 patients were included, 150 in the control group and 59 in the intervention group (mean age: 87.2 ± 5.9 years). The number of PIPs decreased in both groups from hospital admission to discharge (p < 0.001). The number of PIPs, potentially inappropriate medications, and potential prescribing omissions decreased more in the intervention group than in the control group (adjusted intervention effect: −2.46 (95% CI: −2.63; −2.24); −1.13 (95% CI: −1.27; −0.98); and −1.35 (95% CI: −1.52; −1.18), respectively, p < 0.001 for all). Discussion/Conclusion: A CP intervention with an explicit and implicit method improved prescriptions in a UPOG. Further randomized studies are necessary to evaluate the effect of a CP intervention on adverse drug events, health costs, and mortality.

Factors Associated with Potentially Inappropriate Prescribing in Patients on Peritoneal Dialysis

Introduction: Inappropriate prescribing is common in patients with end-stage kidney disease, especially in those over 65 years of age. Our study aimed to reveal potentially inappropriate drug prescribing in patients on peritoneal dialysis (PD) and explore factors associated with this phenomenon. Methods: The research was designed as an observational, cross-sectional study on a convenient sample of 145 consecutive patients with PD who attended the four tertiary-care hospitals in Serbia. The main outcome was the extent of inappropriate prescribing, as assessed by the medication appropriateness index, and potential predictors were tested by multiple linear regression. Results: Inappropriate prescribing was a widespread phenomenon among patients on PD. The main factors that promote inappropriate prescribing in this subgroup of patients on kidney replacement therapy are comorbidities (p = 0.000), increased body weight (p = 0.022), a number of prescribed drugs (p = 0.000), and arterial hypertension on examination (p = 0.030). On the other hand, drinking alcohol and higher systolic blood pressure were associated with a lower inappropriate prescribing. Conclusion: In order to prevent the occurrence of inappropriate prescribing and its severe health or economic consequences, clinicians should pay special attention when prescribing new drugs to high-risk patients.

Appropriateness of antibiotic treatment of acute respiratory tract infections in Tunisian primary care and emergency departments: a multicenter cross-sectional study

BackgroundLittle is known about the pattern and appropriateness of antibiotic prescriptions in patients with acute respiratory tract infections (ARTIs).ObjectiveDescribe the antibiotics used to treat ARTIs in Tunisian primary care offices and emergency departments (EDs), and assess the appropriateness of their use.MethodsIt was a prospective multicenter cross-sectional observational clinical study conducted at 63 primary care offices and 6 EDS during a period of 8 months. Appropriateness of antibiotic prescription was evaluated by trained physicians using the medication appropriateness index (MAI). The MAI ratings generated a weighted score of 0 to 18 with higher scores indicating low appropriateness. The study was conducted in accordance with the Declaration of Helsinki and national and institutional standards. The study was approved by the Ethics committee of Monastir Medical Faculty.ResultsFrom the 12,880 patients screened we included 9886 patients. The mean age was 47.4, and 55.4% were men. The most frequent diagnosis of ARTI was were acute bronchitis (45.3%), COPD exacerbation (16.3%), tonsillitis (14.6%), rhinopharyngitis (12.2%) and sinusitis (11.5%). The most prescribed classes of antibiotics were penicillins (58.3%), fluoroquinolones (17.6%), and macrolides (16.9%). Antibiotic therapy was inappropriate in 75.5% of patients of whom 65.2% had bronchitis. 65% of patients had one or more antibiotic prescribing inappropriateness criteria as assessed by the MAI. The most frequently rated criteria were with expensiveness (75.8%) and indication (40%). Amoxicillin-clavulanic acid and levofloxacin were the most inappropriately prescribed antibiotics. History of cardiac ischemia ([OR] 3.66; 95% [CI] 2.17–10.26; p < 0.001), asthma ([OR] 3.29, 95% [CI] 1.77–6.13; p < 0.001), diabetes ([OR] 2.09, 95% [CI] 1.54–2.97; p = 0.003), history of COPD ([OR] 1.75, 95% [CI] 1.43–2.15; p < 0.001) and age > 65 years (Odds Ratio [OR] 1.35, 95% confidence interval [CI] 1.16–1.58; p < 0.001) were associated with a higher likelihood of inappropriate prescribing.ConclusionOur findings indicate a high inappropriate use of antibiotics in ARTIs treated in in primary care and EDs. This was mostly related to antibiotic prescription in acute bronchitis and overuse of expensive broad spectrum antibiotics. Future interventions to improve antibiotic prescribing in primary care and EDs is needed.Trial registrationthe trial is registered at Clinicaltrials.gov registry (NCT04482231).

Medication Review in Turkish Older Adults at Community Pharmacy: A Pilot Study by Using Medication Appropriateness Index

Objective: The study aimed to evaluate medication review in older adults (≥65 years) at a community pharmacy by identifying the prevalence of potentiality inappropriate medication and calculating medication appropriateness index.&#x0D; &#x0D; Methods: This descriptive study was carried out in a community pharmacy for six months. The older adults (≥65 years) using one or more medications were included. During clinical pharmacist-led medication review; the medication appropriateness index was calculated for each medication of older adults. Potentially inappropriate medications were evaluated according to the 2019 American Geriatrics Society Beers Criteria®.&#x0D; &#x0D; Result: Among a hundred older adults, 46.0% were female. The median age of the patients was 75.5 (IQR, 68.0-78.8). The median number of medications was 9.0 (7.0-10.0). Polypharmacy has been detected in 97.0% of the patients. At least one potentially inappropriate medication was detected in 63.0% of them. The median score of medication appropriateness index score was 53.0 (IQR: 38.6-67.9).&#x0D; &#x0D; Conclusion: To best our knowledge, this is the first study of clinical pharmacist-led medication review by calculating the medication appropriateness index carried out at a community pharmacy in Turkey. There was a high rate of potentially inappropriate medication with a higher score of medication appropriateness in older adults. This study highlights the importance of medication review led by the clinical pharmacist at community pharmacy to optimize medication usage in older adults.

Minding the gap-an examination of a pharmacist case management medicines optimisation intervention for older people in intermediate care settings.

Whilst attention has been paid within the literature to examining potentially inappropriate prescribing (PIP) for older adults in a variety of care settings, less is known about the extent within intermediate care. Furthermore, few studies have examined the utility of clinical pharmacist involvement in this care context. Determine the prevalence of PIP in intermediate care (IC) settings in Northern Ireland (NI), explore the utility of a novel pharmacist case management model at reducing PIP and to examine the association with subsequent healthcare utilisation. Secondary analysis of prospective data (N=532) collected during a medicines optimisation pharmacist case management model in three intermediate care sites in NI. Independent prescriber pharmacists delivered the intervention. Variability in Medication Appropriateness Index score change (ΔMAI) from admission to discharge was examined using multivariate linear regression analysis. Multivariate logistic and Poisson regressions were used to examine the association between ΔMAI and likelihood and numbers of unplanned hospital readmissions within 30 and 90 days of IC discharge. PIP was highly prevalent (89.5%) at baseline with significant reductions in MAI score achieved from admission (Median=14) to discharge (Median=0) (Z=-18.28, p<.001). The prevalence of PIP at discharge was 7.8%. No relationship was observed between ΔMAI score and unplanned hospital readmission. Those who received at least one educational intervention were less likely to be readmitted within 30 days of IC discharge (OR=0.15, 95% CI 0.03, 0.71, p<.001). Baseline healthcare utilisation consistently predicted healthcare utilisation post-IC discharge. Drug-related problems persist for many older adults following acute care discharge and intermediate care may provide an ideal location for medicines optimisation interventions.

Potentially Inappropriate Medication Use in Older Adults with Chronic Kidney Disease.

This study aimed to identify the prevalence of potentially inappropriate medication use (PIMU) in adults above the age of 65 with chronic kidney disease (CKD) according to the American Geriatric Society Beers Criteria (Beers), Screening Tool of Older People's Potentially Inappropriate Prescriptions Criteria (STOPP) and medication appropriateness index (MAI) 30 criteria and to compare them to justify their use in this specific patient group. This was a retrospective and descriptive study conducted between October 1st, 2019 and March 18th, 2020 at Ibni Sina Hospital, Nephrology Department, Faculty of Medicine, Ankara University. Among 269 patients discharged from the hospital during the study period, 100 of them were eligible for the study. The mean age was 73.3 ± 6.9 years and 51.9% of them were male. The prevalence of 35 PIMU was 91%, 42%, and 70% according to the Beers, STOPP, and MAI criteria, respectively. There was a statistically significant difference in terms of prevalence among 3 criteria (p<0.001). Beer detected more PIMU (11.3% vs. 6.4%) and had higher sensitivity among older adults with CKD (0.97 vs. 0.56) compared to the STOPP criteria. Most patients had at least one drug-drug interaction (DDIs) in their discharge prescription (93%) and DDI was one of the main contributors of PIMU. Proton pump inhibitors were the most common medication associated with PIMU in all 3 criteria. The prevalence of PIMU was high among older adults with CKD at discharge according to these criteria. To improve the prescriptions after hospital discharge, it is considered appropriate to use Beers criteria under guidance of a clinical pharmacist.

Multimedication in Family Doctor Practices: The German Evidence-Based Guidelines on Multimedication

Patients with multimorbidity and multimedication require special attention from their treating physicians, as the risks of drug interactions and negative effects on adherence increase with the number of drugs. Most guidelines aim for the treatment of a single disease and do not take potential problems due to multimedication into account. In 2021, updates and evidence-based upgrades of the first version (2012) of the German Guidelines on Multimedication were issued. The aim of the article is to introduce the framework of these evidence-based guidelines, which follows the medication process in six steps: (1) inventory and medication assessment; (2) coordination with the patient; (3) prescription proposal and communication; (4) dispensing of medicines; (5) medication application and self-management; and (6) monitoring. For each step, recommendations and practice tips are presented. The central feature is a structured medication review. The target group is patients with multimorbidity and the concurrent use of five or more drugs. The Medication Appropriateness Index has been modified, and the guiding questions are recommended as guidance for the structured medication review. Overuse and undertreatment are taken into account. The guidelines were consented to in a formal process with 15 medical societies, a patient representative, and experts, as well as piloted in general practices.

How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention.

(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65–74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was −2.42 (95% CI from −4.27 to −0.59) and, between baseline and a 12-month follow-up was −3.40 (95% CI from −5.45 to −1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.